COVID-19 has reinforced the necessity of effective planning of health services, treatment and prevention capacities in primary and secondary care, and both protecting and optimising our healthcare workforce. Here, Professor Kath Checkland reflects on the renewed centrality of “commissioning” to health policy debates that will follow in the wake of the pandemic, and draws lessons from research here at Manchester for the policymakers and practitioners who will need to address this debate in the months to come.
- “Commissioning”, that is, planning to ensure the right services and sufficient capacity within the healthcare system, is both complex and essential.
- Since 2012, the healthcare system has become more fragmented, making commissioning roles more difficult and prompting recent drives towards greater integration and collaboration.
- The COVID-19 crisis will raise important questions about structures of decision-making and the appropriate levels for roles and responsibilities in planning.
- Future policy direction needs to take into account with value of high-quality management and relationships, which underpin effective commissioning but are not currently ‘priced-in’ to existing thinking on commissioning.
The organisation and management of the NHS can seem to be a dry subject, full of esoteric language and highly technical details. Acronyms abound, with NHSE overseeing CCGs which in turn support PCNs whilst contributing to ICSs, with CQUINs offering incentives – with the LTP setting out the strategy for the next 10 years. And if you understand that sentence then you have clearly spent far too much time reading about government policy!
However, one thing that the current crisis has taught us is that the oversight and management of the NHS matters. Planning – usually known in the NHS as commissioning – is the function which ensures that the right services are available for the right people at the right time. Providing sufficient capacity in both hospitals and community services, and co-ordinating between different types of care providers to make sure that patients experience joined up services require complex systems and oversight. As the NHS and social care services adapt to and recover from the pandemic, it is important to consider how planning works, and how it may need to change.
Development of organisation and planning from 2012
In 2012 a vast reorganisation of the NHS took place which affected all parts of the system. Our team has been researching these changes for the past 8 years and in a recently published book we offer a comprehensive overview of the changes made and their impacts on the governance, accountability and functioning of the health system in England.
The Health and Social Care Act 2012 distributed responsibility for commissioning services to a much wider range of organisations, and required service providers to compete with one another to a greater degree than in the past. Public health was moved outside the NHS to Local Government, and a new Arm’s Length Body, NHS England, was established to oversee the service as whole. The result was a significant fragmentation of care planning across the NHS, with some emerging evidence of a potential deterioration in the provision of some types of care.
Less than 10 years after its enactment, many of the principles underlying the Act have been discarded, with a move away from competition and a new focus on collaboration and integration of care. However, the legislative structures put in place in 2012 remain, and the new collaborative structures which are being built rest upon agreements and partnerships rather than being enshrined in statute. Our research found that confused lines of accountability could be a problem, and that skilled managers with a good knowledge of their local area were vital in the planning process. The fragmentation which resulted from the Health and Social Care Act was at least partially mitigated by the hard work of skilled commissioning managers who, in their words, ‘knitted the system back together’. We also observed that different functions require activity on a different scale, with planning of primary care services needing a much more local focus than larger scale hospital reorganisations and collaborations to deliver more specialised services.
The building blocks of the more collaborative system set out in the NHS Long term Plan of 2019 include collaborations across populations of 1-3 million, known as Integrated Care Systems (ICS), and local neighbourhood collaborations between GP practices and other community-based services, known as Primary Care Networks (PCN). ICSs are focused upon the big issues of resource distribution between hospitals and the best way to organise services such as emergency care and specialist surgery. PCNs are focused upon how best to provide services outside hospital, with GP practices working together with other community services to provide comprehensive services and hopefully keep people out of hospital. Clearly the current pandemic will have affected these developments, with collaboration at all levels even more important in the current emergency.
Organisation and planning: lessons for the future
So what can we learn from our research to date which may be relevant to regional collaboration (in Integrated Care Systems) and in local neighbourhood working (in Primary Care Networks) as they develop and work together to manage the crisis?
- The NHS which emerged from the Health and Social care Act 2012 is a very complicated one, with overlapping layers of regulation and accountability. The Covid-19 crisis has led to a centralisation of many aspects of NHS decision making, and this may well be appropriate for short term crisis management. However, as the NHS returns to normal it may be that this is an appropriate time to consider the level within the system at which different types of decision are made. Our studies have raised the question as to whether the regional level of co-ordination should be put on a statutory footing, as used to be the case with Strategic Health Authorities. The different pace and impact of the pandemic in different areas suggests that a regional tier of management with a clearly defined role, responsibilities and lines of accountability may offer considerable advantages in the recovery period and in the longer term.
- Our research highlighted the complex regulatory structures to which NHS organisations are subject, from national inspection regimes to the application of EU law on procurement. The current crisis has led to the short term suspension of many regulatory requirements, such as individual practitioner revalidation and CQC inspections. It is much easier to increase regulation than it is to reduce it, and this may be an opportunity to critically examine each element of the regulatory system to consider how and in what circumstances it adds value or prevents avoidable harm, only re-introducing those where a clear rationale can be described.
- Our research has shown that the planning and management of primary care requires detailed local knowledge, and the pre-Covid 19 push for Clinical Commissioning Groups to merge and cover much larger populations may make this more difficult. In the aftermath of the pandemic there will be an opportunity to critically examine how local services adapted and what factors helped them to do that. A measured consideration of what planning functions need to take place over what geographical scale would be of value, and could inform future decisions as to optimum CCG size.
- One of the drivers of CCG mergers is the reduction in management costs. All of our studies have shown that high quality management is of vital importance in the delivery of high quality NHS services, and that personal knowledge and relationships underpin the planning and delivery of these services. Valuing managers and the relationships that they have built should be the cornerstone of the NHS as it builds for the future.